The Facts About India’s Infant “Sex Changes”

Canadian and international press outlets reported last month that in India, the preference to have male children is so strong that parents are having their female infants surgically assigned (a.k.a. “sex changes”) to male. There were all sorts of problems with this story, but some of the verdicts have come in. Here are the facts (to the best of our available information) of the matter.

In a stunning revelation reported in The Telegraph Monday, parents in India are allegedly paying £2,000 (around $3200) to have their young daughters undergo gender reassignment surgery in order to turn them into sons — all in the hopes of dodging the added expense of raising a girl. Indian culture favors males for their income earning potential and due to the fact that unlike females, they won’t cost their families unnecessary educational expenses and wedding dowries.

Currently, there are 7 million more boys than girls under age six in India and there’s clearly a reason for that. In a country where female foeticide (gender-based abortions) are commonplace, this new twist has many fearing children aren’t safe even after they are born. Madhya Pradesh state government is already investigating 300 cases in which girls have reportedly undergone genitoplasty.

Some news sources in India had been clarifying that the infants being surgically assigned to male are intersex, which is still bad (and I’ll explain why shortly). “Intersex” covers a wide range of medical conditions in which a child is born with genetic, gonadal and/or morphological traits that don’t exactly match the ways we define “male” or “female.” The medical establishment sometimes uses the term “Disorders of Sex Development,” but intersex advocates almost overwhelmingly find that terminology stigmatizing and offensive. Some intersex conditions aren’t immediately obvious (such as Klinefelter’s Syndrome) and a person might go entirely through life without knowing that they have such a condition. Others have more physically visible traits, which clinicians often feel is their duty to “correct.”

While some media outlets have been reporting the intersex connection, others have been leaving the impression that it is a widespread problem resulting in surgery for any infant, intersex or cissexual. The Telegraph article being referenced attempts to resolve this by stating that some parents are coercing or bribing doctors to misidentify newborns as intersex, so that surgery can be performed — though they don’t indicate a source for this information.

This inevitably spun off some far-right media rhetoric, using the idea of sex-selective infant “sex changes” to validate their campaigns against abortion in China and India (and by extension, all abortion), since it’s a grey area they can win support with. It’s worth noting, though that some pro-choice organizations like the Center for Genetics and Society have also spoken out against sex-selective practices, commenting that even the U.S. has seen a rise in preimplantation genetic diagnosis (PGD) and sperm sorting used to select the sex of a child:

Sex selection raises concerns about exacerbating sex discrimination and violence against women, and normalizing the “selection” and “design” of children. The use and marketing of sex selection technologies are largely unregulated in the United States. Although the ongoing attacks on abortion rights complicate efforts to address even pre-pregnancy methods, a number of countries—including Canada, Germany, and the United Kingdom—prohibit “social” sex selection without affecting abortion rights.

Disparity in Value

The most apparent issue that mainstream media has taken from this story is the glaring difference in value that Indian society (as with many other parts of the world) places on males, as opposed to females. It’s certainly likely that disparity in gender valuation factors into parents’ decisions when surgical assignation of gender occurs in China and elsewhere (even here). And if the practice is being abused in India, it’s certainly conceivable that it’s being similarly abused elsewhere. Ms. Magazine comments on the harms caused by sex-selective practices:

Its consequences are anything but abstract in the regions of South and East Asia where the wildly skewed sex ratio among the generation now coming of age is associated with an upsurge in trafficking of women for sex and for marriage–to the extent that some poor villages are empty of young women. And some of the most alarming sex ratios are in affluent areas; economic and technological developments are in fact driving sex selection rather than discouraging it by encouraging smaller families, which leads people who value sons to do whatever is required to ensure one.

India is facing a significant disparity between male births and female births, having become one of the nations considered notorious for sex-selective abortion (perhaps even second to China). The Telegraph quotes a figure of 866 girls being born for every 1000 boys in India, from the Centre for Social Research’s Ranjana Kumari, who adds:

“People don’t want to share their property or invest in girls’ education or pay dowries. It’s the greedy middle classes running after money. It is just so shocking and an outright violation of children’s rights.”

The government needed to address the problem by stressing the spiritual value a girl or woman brought a household in Hindu culture. “In India we say God resides in that house where there’s a woman but that has evaporated because of all this greed. We need to emphasise the spiritual wealth a girl brings to a family, but we also need to support them with financial subsidies and jobs,” she added.

In the article that first broke the story, The Hindustan Times claims that these surgical assignments have been happening “by the hundreds,” and to children who are up to 5 years old:

About seven paediatric surgeons from Indore – who are associated with top private and government hospitals – perform these surgeries…

Another Indore paediatric surgeon performing this procedure, Dr. Brijesh Lahoti, said, “In India, there is no problem in performing these surgeries as only the consent from parents and an affidavit is required. These are reconstruction surgeries where sex of the child is determined based on its internal organs and not just on the basis of external genitalia.”

A senior consultant urologist at the Sitaram Bhartia Institute in Delhi, SV Kotwal, wrote to the Hindustan Times to justify surgical reassignment procedures for intersex infants, clarifying that this is very different from reassignment surgery for transsexuals:

Each year, many children are born with ‘manufacturing defects’ in their sexual organs like undescended testes. Little boys with advanced forms of hypospadias are often mistaken for girls and are even brought up as girls.

Left untreated, they grow up into imperfect adults, and urologists, paediatric surgeons and reconstructive surgeons strive legitimately to correct such defects. The surgeon correcting it is not really changing sex, he is only correcting a congenital defect. Also, such surgeries must be performed before the age of three. Correction of ambiguous genitalia is a legal and validated procedure and it shouldn’t be confused with ‘sex change’.

[He then compares to phalloplasty:] … The surgery is long and taxing, particularly the female-to-male one. One of our patients spent 25 hours on the operation table! Many secondary corrections are made and the final outcome may even take a couple of years. It is only then that the person can assume his pre-ordained sexual role, albeit a sterile one. Can you imagine this procedure being carried out on ‘scores’ of little children in one stage in places that lack proper facilities?

We’ll get to his excuses for infant surgical assignment in a moment, but his point about the complexity of F2M genitoplasty and unlikelihood of applying it to cissexed infants is worth examination. There are two main types of F2M surgeries: phalloplasty and metoidioplasty. The former (which seems closer to what Kotwal describes) uses a graft using donor tissue from elsewhere on the body, and is a long, intensive surgery that would be probably too strenuous on a newborn or young child. It’s also highly unlikely to yield a result that would be considered “passable,” (as much as I hate using that word) functional and mature accordingly as the child develops. The latter is sort of a clitoral release and then uses hormone therapy to do the rest. Most intersex “corrective” techniques rely on some existing genital formations to work with, thus averting some of the difficulties of F2M genitoplasty, although some things like rerouting / extending the urethra are performed regardless. It’s highly unlikely that phallo would be performed on so young a patient, but it is conceivable that some “quick fix” surgical procedure could be developed based on metoidioplasty. But even then, again, development during puberty would be very complicated.

It is totally a failure of media to go in to detail of the issue.I have talked to all the pediatric surgeons of the city and I am confident to say that Nothing like this is going on in Indore,it is a baseless news.As a resposible office bearers of IAP “Indian Academy of Pediatrics” I would like to say categorically that this is the case of negative journalism on the part of HT. is also shocking and surprise for me.We should condemn it as news paper has opened another areas of discussion and need for the parents who are desirous of son , in-turn which will again confuse our society.

It wouldn’t be the first time that a newspaper has published a sensationalist beat-up regarding Intersex issues. It also wouldn’t be the first time an Indian state government official with an obvious political agenda has tried a cover-up.

So there you go. I’ve intentionally given you the back story before the answer, because it’s important to know the sociopolitical forces providing this backdrop, and care about the surgical assignment techniques on infants (whether intersex or cissexual), since the practice is still very often damaging.

The Answer

The Hindu reports that this is indeed in reference to the surgical assignment of intersex infants. They also cite medical professionals, but not an investigation, which might be a noteworthy distinction to make.

However, that report still whitewashes the phenomenon of sex selection, and leaves the impression that it is purely biology that is playing into the decision to assign male gender and perform male genitoplasty. Given the reality of the disparity in India, there is more than ample reason to question that.

It also discusses the surgical assignation of sex as though it’s some saintly task performed by the medical community. It isn’t.

From their report:

At least one figure — which sparked off much of the national alarm — is provably dubious. The article said that “genitoplasty experts of Indore say each of them have turned 200 to 300 girls into ‘boys’ so far,” listing seven such experts.

“Well, three doctors told us they had done about 200, 300 surgeries,” Mr. Majumder told The Hindu, not explaining how that figure was then extrapolated to include the remaining four doctors. He then admitted: “Initially, the doctors may have thought our article would be a good advertisement for them, so they may have exaggerated.”

Most of the rest is peppered with glee at having caught a rival newspaper in the embarrassing situation of having headlined with a badly-researched story.

The bottom line is that it’s most likely that cissexual infants are not being surgically assigned a gender. But it’s also most likely that sex-selective practices are resulting in intersex infants being overwhelmingly being assigned to male — probably whenever it’s biologically possible — regardless of how they might identify later in life. That is speculative on my part, but based on the consideration that with all that has been written thus far, there has likely been some real disparity that sparked the several initial reports.

“Imperfect Adults” and the Perceived Nobility of “Normalizing” Intersex Children

With regards to Kotwal’s and others’ excuses, OII Australia counters that these procedures are as harmful to intersex children as they would be to cissexual (non-intersex / non-trans) children:

… There is no secret formula, no special knowledge or technique, no machine that goes ping. The only way they can determine the sex of the infant is to ask them when they are old enough to speak. All children, or almost all children, whether intersex or not, know what sex they are. Their brain tells them so. There is no special procedure or special evidence other than this.

… These surgeons are imposing a gender – whether boy or girl, man or woman – on these children regardless of whether they are intersex and male, or intersex and female, intersex and neither male nor female, or intersex and both male and female. The surgeons are creating confusion where none exists for the child.

Surgical assignment of intersex infants stems from Dr. John Money’s philosophy that gender identity is malleable and can be changed through clinical conditioning. When Money wrote about this, he pointed to his star example, “John/Joan,” who was an infant whose penis was burned off in a circumcision accident — and then under Money’s guidance was raised as a girl. “John/Joan” is now known to have been the late David Reimer. In 2000, Dr. Milton Diamond uncovered the truth about David Reimer’s tragic story and John Colapinto broke the story. He recaps for Slate Magazine:

After David’s suicide, press reports cited an array of reasons for his despair: bad investments, marital problems, his brother’s death two years earlier. Surprisingly little emphasis was given to the extraordinary circumstances of his upbringing.

… At age 2, Brenda angrily tore off her dresses. She refused to play with dolls and would beat up her brother and seize his toy cars and guns. In school, she was relentlessly teased for her masculine gait, tastes, and behaviors. She complained to her parents and teachers that she felt like a boy; the adults—on Dr. Money’s strict orders of secrecy—insisted that she was only going through a phase. Meanwhile, Brenda’s guilt-ridden mother attempted suicide; her father lapsed into mute alcoholism; the neglected Brian eventually descended into drug use, pretty crime, and clinical depression.

When Brenda was 14, a local psychiatrist convinced her parents that their daughter must be told the truth. David later said about the revelation: “Suddenly it all made sense why I felt the way I did. I wasn’t some sort of weirdo. I wasn’t crazy.”

Although not intersex himself, Reimer’s story has resonated over the years with many intersexed people (and many transsexuals as well, although no concrete connection to intersex has yet been determined for transsexuality). To be fair, there are intersex people who are happy with the sex they live and/or have been raised as, but there are also many who identify as the opposite sex or as non- or dual-sexed in some way. Many intersex advocates call for surgical assignments to be delayed at least until the child can be old enough to indicate who he or she is.

We campaign against all non-consensual normalisation treatments of infants that are not medically necessary and favour the right of all intersexed children to determine their own sex identity once they are capable of communicating it to us. Furthermore we advise parents to respect the sex identity of their children and to do all that is necessary so that their children can live according to their choice.

Once the child has communicated clearly their own sex identity, it is crucial that the child’s identity be respected both by the parents, physicians and therapists who are caring for the child. All steps should be taken to respect the child’s own sense of self by being given access to all health care necessary to facilitate life in the sex the child considers most appropriate.

Therefore, we are campaigning in favour of changing the current medical paradigm concerning nonconsensual normalisation treatments and against the diagnosis of gender dysphoria or GID in intersex individuals who feel they were assigned the wrong sex. OII affirms that the true sex of the child is determined by their own inner psychological perceptions and that the right of individual intersex persons to affirm their own sex without medical or governmental interference should be a basic human right.

Curtis Hinkle also goes into further detail in an article entitled “Mutilations or non-consensual normalization treatments?” (it’s worth reading the whole article):

… Instead of insisting on a gender identity assignment as quickly as possible, OII is convinced that it would be better to inform the parents of their child’s physical difference in such a way that they will be able to make informed decisions about the real health needs of their child (and not all this focus on which gender identity is best for the child which is what we are doing now). Understanding the intersex variation and the anatomical, endocrinological and other physical differences are very important and this can be very difficult for parents who are usually not specialists in genetics or anatomy. They need help to manage the health care decisions concerning their child and understanding their child’s body is what is important – not spending weeks deciding what gender identity is most appropriate. This wastes precious time and it makes the parents feel their child is so different that they can be overwhelmed, shocked and confused….

This matters, because the surgical assignment of gender to intersex infants is not simply something that happens in India. It happens in North America on an almost routine basis, although not all pediatricians and surgeons encourage the procedure.

I want to be clear that I don’t speak for intersex people, and defer to the experiences of those who have been surgically assigned as infants. When in lieu of those experiences, I present what I know to the best of my ability.

But if this story can finally draw attention to the plight of intersex children, then that’s probably a good thing.

If you are a part of the medical establishment, investigate whether surgical assignation of intersex infants is performed in your area, and promote a harm-reduction approach that allows a child to grow and develop, and decide when they are better able to communicate who they are.

If you’re concerned with the disparity in value placed on women in nations like China, India and elsewhere around the world — disparities at the root of sex-selective abortion and sex-selective surgical assignment, do a search for organizations in those nations directed by women, and donate what you can to support them. It’s always wisest to support existing programs directed by people who live in those cultures and understand the nuances, than to presume a North American organization will just know best, but if you don’t have the time and resources to seek those organizations out, then support Human Rights Watch, which works with many of those organizations.

I don’t know if EKTA or any other organization is looking specifically into whether sex-selective practices are influencing decisions on surgery in India (or China, or elsewhere, for that matter). If I learn of any, I will follow up this post with information.

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